INCONTINENCE AND GENITAL PROLAPSE DR. IQBAL TURKISTANI Asst. Prof. & Consultant Ob/Gyn

Basic Anatomy of the Lower Urinary Tract (LUT) in women The LUT composed of the Bladder and Urethra in a functional unit serving the two purposes of storage and voiding during the micturition cycle. These structures are supported by the pelvic floor.

The Urinary Bladder: - Is a hollow, muscular organ which: - acts as a compliant reservoir for urine - It comprises the Bladder wall & Bladder cavity in which urine collects

The Bladder wall is composed of several layers The Detrusor: Is a complex network of smooth muscle fibers and elastic tissue  which allows the bladder to expand without pressure during bladder fillings and is responsible for bladder contraction during voiding.

The Trigone  is a small muscular triangular area, lying at the posterior wall of the bladder, next to the bladder neck.  functions to prevent reflux of urine to the upper urinary tract during voiding.  the two ureters enter the bladder at the superior angles of the trigone.  at the lower most apex of trigone is the opening of the bladder through the bladder neck to the Urethra.

2. Urothelium: - The epithelial lining of the detrusor - Is smooth at trigone and folded into rugae on the the rest of the bladder when empty

II: The Urethra and Sphincters The female urethra is a fibro- muscular tube  3.5 cm long Consists of outer layer of striated muscle fibres, and an inner layer of smooth muscle fibres, lined by the mucosa, submucosal vessels and connective tissues.

1. The Urethral Sphincters: Two mechanism to control urine flow in women: A. The smooth muscle sphincter (Bladder neck and proximal urethra)  is a physiological but not anatomical sphincter  Under involuntary control  keeps the bladder and upper urethra closed during the storage phase

2. Mucosa and submucosa: B. The Striated Sphincter: = Striated musculature, which is part of the outer wall of proximal urethra (intrinsic sphincter) + bulky skeletal muscle group lateral to the urethra at the level of the middle segment in female (extrinsic sphincter) 2. Mucosa and submucosa: Urothelium lining the urethra - beneath is a vascular pelxus  helps form water tight seal

THE PELIV FLOOR The pelvic organs are supported and maintained in the correct position by the “Pelvic Floor” - This is mainly composed of the LEVATOR ANI group of muscles - Lined by the Endopelvic fascia ,which is a continuous mass of tissue with various thickened parts - the largest being the arcus tendineus fascia pelvis - the endopelvic fascia attaches the vagina to the pelvic sidewall.

Urogenital hiatus = the opening within the levator ani muscles through which the urethra and vagina pass. The constant activity of levator ani muscle (like that of postural muscle)  closes the lumen of the vagina eleminting any opening within the pelvic floor. The interaction between the pelvic floor muscles and supportive ligaments is critical for pelvic organs support Although the ligaments can sustain the load of the pelvic organs for a short period of time, they ultimately fail to hold the vagina in place if they are not assisted by the pelvic floor muscle musculature. This happens when the muscles are damaged or paralised.

: PHYSIOLOGY MICTURITION CYCLE The micturition cycle is composed and alternate between:  Storage phase  Voiding phase A normal micturition cycle requires a coordination and adequate interplay between the Reservoir and Outlet Functions of the LUT structures inlcuding:  The detrusor muscle  The urethral smooth muscle  The striated urethral sphincter  The pelvic floor muscles (PFM)

Filling and Storage: Bladder accommodation during filling is primarily a passive phenomenon It depends on the Elastic Passive Phenomenon dependent on the elastic properties and visicoelastic properties of the bladder wall and an increase in the outlet resistance by the striated sphincter. Continence is maintained during increases in intra abdominal pressure by the intrinsic competence of the bladder outelet (bladder neck and proximal / mid urethra) and the pressure transmission ratio to this area with respect to the intravesical contents.

EMPTYING AND VOIDING Can be voluntary Or involuntary Involves inhibition of the spinal somatic and sympathetic reflexes and activation of the vesical parasympathetic pathways, the organizational center (brain stem). Initially there is relaxation of the outlet musculature mediated by cessation of somatic sympathetic spinal reflex. Contraction of the bulk of the bladder smooth musculature occurs through a highly coordinated parasympathetic input. With amplification and facilitation of the detrusor contraction from other peripheral reflexes and from spinal cord supraspinal sources and the absence of anatomical obstruction between the bladder and the urethral meatus  Complete Emptying will occur.

URINARY INCONTINENCE (UI) Definition: Incontinence is the involuntary loss of urine. Urine leakage(incontinence) occurs when the pressure in the bladder (expulsive force) exceeds that within the urethra (closure force).

CLASSIFICATION OF UI: 1. Urgency Urinary Incontinence (UUI)`~22% = involuntary leakage occurs with a strong, sudden, and uncontrollable desire to urinate as result of involuntary detrusor contraction. 2. Stress Urinary Incontinence (SUI): (49%) = involuntary leakage on effort or exertion or on sneezing or coughing, as a result of insufficient urethral closure pressure. 3. Mixed Urinary Incontinence  29% = UUI + SUI

The symptomatic definitions can be supported by signs from physical examination: e.g.- urine leakage during stress / cough test - Urodynamic testing such as filling cystometry (e.g. involuntary detrusor contractions during the filling phase)

OAB / Overactive bladder: = Symptoms of urgency with or without urgency inconti -nence usually with frequency and nocturia. (frequency> 8 mict day time) (nocturia> 2mict at night) = UUI and mixed urinary incontinence are only part of the OAB

DETRUSOR OVERACTIVITY: = Is a urodynamic observation characterized by involuntary detrusor contractions during the filling phase. N.B. - Not all OAB patients show DO - DO can be found on urodynamic studies without complaints by the patient of OAB symptoms

I. URGENCY INCONTINENCE 1. Definition: = The complaint of involuntary leakage, accompanied by / immediately preceeded by Urgency. = The symptoms are due to an Overactive Detrusor muscle that contracts inappropriately during the filling phase = The symptoms caused by the overactive bladder are typically:  Frequency  Urgency  Urge incontinence

Frequency = emptying the bladder more often than 8 times a day. Urgency = strong compelling desire to urinate which is difficult to defer. Nocturie = Night time frequency which disrupts the sleeping pattern, resulting in tiredness that may affect all aspects of social life.

2. AETIOLOGY: Urge incontinence is mainly secondary to OAB. A. IDIOPATHIC DETRUSOR OVERACTIVELY = Majority of cases = Pathophysiology of DO is not fully understood / no objective causes are found. However several explanations have been proposed: 1.  Supra pontine inhibition 2.  Afferent activity 3.  Sensitivity of detrusor to Acetyl choline

B. Neurogenic detrusor overactivity In this case, there is an objective evidence of neurological disease e.g. multiple sclerosis, upper motor neuron lesions, peripheral nerve lesions following pelvic surgery.

II: STRESS INCONTINENCE (SI) 1. Definition: As a result of variable combination of:  intrinsic urethral sphincter muscle weakness  and anatomical defect in urethral support leading to insufficient closure pressure in the urethra during physical effort, e.g. lifting, coughing, sneezing, and running.

2. AETIOLOGY: multifactorial Pregnancy Damage to the pudendal n. during childbirth contributing to~~~~~~ Vaginal delivery ~pelvic floor and sphincter denervation Pelvic surgery ~~Damage to the pelvic nerve (autonomic) during extensi ve pelvic surgery can de- nervate the urethra. Neurological ~~central or peripheral causes neurological problems can disrupt the continence mechanism. Lifestyle ~~ abdominal pressure ~~ Stretching of perineal muscles Promoting causes~~Due to mainly aging and co-morbidities.

III: MIXED INCONTINENCE The complaint of involuntary leakage associated with urgency and also with effort, exertion, sneezing and coughing

EVALUATION History: Personal detail Urological Symptoms: & incontinence symptoms  How often ? D/N  How much urine do you leak?  Stream / incomplete emptying Other associated symptoms:  Childhood enuresis  Dysuria  Perineal discomfort / vaginal prolapse  Sexual problem  Rectal soiling Quality of life assessment How much does leakage of urine interferes with your everyday life! 0  10 scales Not at all a great deal

OBS/GYN HISTORY MEDICAL HISTORY: Menstrual Pelvic Surgeries Pregnancy Delivery Pelvic radiotherapy MEDICAL HISTORY: Chronic cough, constipation Cardiac problem / failure Renal failure Endocrine problem Neurological problem (Parkinson, multiple) Sclerosis, spinal injury)

DRUGS: PHYSICAL EXAMINATION Sedatives , Diuretic,Anticholinergics Anxiolytics, Alcohol, Caffines, Tobacco…etc PHYSICAL EXAMINATION To check for aetiological conditions that may contribute to UI and that might affect the choice of treatment

I. General Exam:  Ht, & Wt  BMI - Obesity, is a risk factor for UI  Abdominal exam  scars, distended bladder, masses  Neurological exam Concentrating on sacral segment

II. Perineal/Genital Examination 1. Perineal skin for Excoriation and erythema due to incont. 2. Stress test – cough 3. Extra urethral incontinence = urine leakage through channels other than urethra e.g. urogenital fistula (urethro-vaginal, vesico- vaginal, vesico-uterine) 4. Assess bladder neck mobility, and presence of pelvic organ prolapse (POP) especially with cough / strain 5. Vaginal Exam: Assess pelvic muscle function for resting tone and pt’s ability to perform a pelvic floor contraction 6. Rectal exam: Anal tone, pelvic floor function and the consistency of stool.

INVESTIGATIONS: Standard Urine Analysis / reagent strip to R/O UTI / microscopic heamaturia Biochemical tests  Renal function  Prior to surgery 3 Postvoid Residue (PVR) Ultrasound or catheterization If > 30% of total bladder capacity (50-100 ml) = significant Pad test 1 hr / 24 h. test = Quantify urine loss > 1 g = +ve 1 hr test > 4 g = +ve 24 hr test

URODYNAMIC TEST The only way to precisely define bladder and urethral function Allow characterization of pathophysiological aspects of the various symptoms Help to determine the prognosis and guide choice of therapeutic strategy Uroflowmetry: = measures urine flow rate = Indicates outlet bladder obstruction Cystometry ~~ Filling ~~ Voiding